Check insurance coverage! (610) 936-8214

Financial Hardship Request | For All Payers (Medicare and Commercial)

Patients with Commercial (Private) Insurance

In addition to relevant laws, private payor contracts generally require that the provider collect copays and deductibles. Failure to do so without the payor’s express approval would violate the contract terms and could result in claims for breach of contract or repayment. The health care provider may, however, elect to waive all or a portion of the Medicare patient responsibility if the health care provider determines that the beneficiary does not have the ability to pay. To assist us in determining if you have the ability to pay, please answer the following questions:

Medicare:

Medicare law requires a health care provider that accepts an assignment for services billed to the Medicare program, to bill the beneficiary for their portion of the cost of these services. The health care provider may, however, elect to waive all or a portion of the Medicare patient responsibility if the health care provider determines that the beneficiary does not have the ability to pay. To assist us in determining if you have the ability to pay, please answer the following questions:

Fill out the form below, or click here to download a soft copy version.

Financial Hardship Waiver

To assist us in determining if you have the ability to pay,
please answer the following questions.

Applicant Information

First Name *

Last Name *

Date of Birth *

Insurance ID Number

Street Address *

Street Address 2

City *

State *

Zip Code *

Email Address *

Net Monthly Income from All Sources

Family Size

Financial and Insurance Information

1. Are you receiving any type of financial assistance from local,
county, state, or federal government agencies? *

YesNo

If yes, describe this assistance

2. Do you have other health insurance in addition to Medicare
or the private insurance we have on file that covers
health-related products or services? *

YesNo

If yes, provide the name, address, and phone number of the coverage

3. Is a trust, guardian, or anyone else legally responsible
for your medical bills? *

YesNo

If yes, provide the person's name, address, and phone number

Certification and Consent

Electronic Signature — Type Your Full Name *

Date *

By typing your name above and submitting this form, you confirm
that your typed name is intended to serve as your electronic signature.

First Name

Last Name

Date of Birth

Street Address

Street Address 2

City

State

Zip

E-Mail Address

Medicare/Insurance ID Number

Net monthly income from all sources

Family size

1) Are you receiving any type of financial assistance from local, county, state, or federal government agencies?

Yes No

If yes, describe this assistance:

2) Do you have other health insurance in addition to Medicare that covers health related products or services?

Yes No

If yes, give the name, address, and phone number of coverage

3) Is a trust, guardian or anyone else legally responsible for your medical bills?

Yes No

If yes, give the name, address, and phone number of this person.

4) Do you own your own home?

Yes No

5) How much do you have in savings to which you have immediate access?

Yes No

POVERTY GUIDELINES FOR THE 48 CONTIGUOUS STATES & THE DISTRICT OF COLUMBIA

SIZE OF FAMILY UNIT	POVERTY GUIDELINE	200% OF POVERTY GUIDELINE
1	$13,590	$27,180
2	$18,310	$36,620
3	$23,030	$46,060
4	$27,750	$55,500
5	$32,470	$64,940
6	$37,190	$74,380

I certify that the above information is true and correct and I request that the Medicare patient responsibility or a portion of it be waived. I agree to provide proof of all information above in the form of pay stubs, bank statements or any necessary documents to prove inability to pay.

I have reviewed and agree to the MVM Health Privacy Practices (click to review)

Digital Signature: Please type in your full name to sign.